Camarillo Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Camarillo, California.
- Location
- 205 Granada Street, Camarillo, California 93010
- CMS Provider Number
- 555770
- Inspections on file
- 34
- Latest survey
- April 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Camarillo Healthcare Center during CMS and state inspections, most recent first.
Surveyors found a hole in the dining corridor wall with detached siding, visible moisture inside the wall, and ants entering and exiting the opening. The damage was partially obscured by equipment, and staff were unaware of how long the issue had existed. The area was not blocked off or marked to indicate repairs were in progress.
A resident's attending physician did not consistently review or update the medication list at each required visit, resulting in progress notes that inaccurately reflected the resident's current medications. Additionally, the physician failed to write, sign, and date progress notes at each visit, and these notes were not present in the medical record until much later, leading to discrepancies in documentation timing.
A resident did not receive physician visits within the required 60-day intervals, as shown by gaps of 86 and 91 days between visits. The facility's policy and interviews with the MRS and DON confirmed that physician progress notes and timely evaluations were not completed as required.
A facility failed to assess and document pressure ulcers for a resident, including a right buttock ulcer identified but not assessed. Additional ulcers on the left buttock and sacrum were incompletely assessed. The resident refused repositioning, but no assessments were documented regarding this refusal. The facility's policies on nursing assessment and pressure ulcer management were not followed.
The facility failed to treat a resident with dignity during a room change, leaving them unable to reach their call light and personal items. Additionally, another resident was found with a strong odor and inadequate hygiene care, despite records indicating otherwise. Interviews revealed that housekeeping staff moved the resident, contrary to policy, and there was confusion about the hygiene care provided.
A facility failed to document a resident's advance directive (AD) in the re-admission agreement, despite the AD being completed and presented upon readmission. The discrepancy was confirmed through a review of the resident's electronic health record and interviews with the Director of Admission (DOA). The facility's policy states that a POLST should complement an AD, but the re-admission paperwork did not reflect the resident's AD, potentially leading to conflicts with the resident's healthcare wishes.
The facility failed to maintain a safe and homelike environment for two residents, with issues such as a broken drawer and electrical outlet cover. Additionally, the facility lacked monitoring of hot water and air conditioning temperatures, potentially affecting residents' comfort and well-being.
A resident with multiple health issues, including congestive heart failure and chronic respiratory failure, was observed eating while lying flat in bed, posing a risk of choking and aspiration. The facility failed to include interventions in the care plan to address the resident's refusal to sit upright or to educate the resident on the risks. Interviews with staff revealed a lack of documentation and physician notification regarding the resident's eating position preference.
A facility failed to monitor a resident for signs of bleeding while on the anticoagulant Eliquis. The MAR showed an order for Eliquis 2.5 mg twice daily, but there was no documentation of monitoring for bleeding. This was confirmed by the MDS coordinator. The facility's policy requires ongoing monitoring for safe medication use, which was not followed.
The facility failed to dispose of expired medications per policy, as observed during an inspection. Three expired medications, including Latanoprost, Prednisolone Acetate, and Brinzolamide, were found in a medication cart. A licensed nurse confirmed the medications were expired and needed disposal. The facility's policy requires expired medications to be removed from use.
A facility failed to follow a physician's order for a renal diet with no added salt (NAS) for a resident on dialysis. A salt packet was found on the resident's lunch tray, despite the diet order indicating a renal diet. The RD confirmed the diet should exclude added sodium, and the DSD stated the salt packet was not removed due to the meal card not specifying NAS. The resident's Order Summary confirmed the NAS diet prescription.
The facility failed to maintain sanitary conditions in its food storage and distribution areas. Debris and grime were found in the dry storage area, and ice chests used for resident ice distribution were not cleaned as per policy. These lapses had the potential to cause foodborne illness among residents.
The facility failed to follow infection control practices, including improper PPE use for a resident on EBP, unlabeled oxygen and IV tubing, and incorrect storage of respiratory equipment. Staff acknowledged these lapses, which were contrary to facility policies.
Two residents experienced unmet needs due to staff failing to follow the facility's call light policy. One resident's call light was turned off without addressing a malfunctioning bed remote, while another resident with significant medical conditions was left unattended after activating the call light for assistance. The facility's policy requires staff to address residents' needs before turning off call lights, which was not followed.
The facility failed to display 'OXYGEN IN USE' signs outside the rooms of two residents receiving oxygen therapy, as required by policy. This was confirmed through observations and interviews with staff, including a supervisor and a CNA, who acknowledged the absence of the signs and the responsibility of nurses to ensure their placement.
The facility failed to ensure proper physician justification for the use of Xanax beyond 14 days for a resident, lacking documented rationale for extending the PRN order. Additionally, informed consents for psychotherapeutic medications for another resident were missing a physician's signature, as confirmed by the DON.
A facility failed to communicate a resident's skin condition to the receiving home health agency (HHA), resulting in a delay in necessary treatment. The resident, discharged with multiple diagnoses, had pressure ulcers and moisture-associated skin damage that were not conveyed to the HHA. The Social Services Director claimed the skin assessments were faxed, but the HHA did not receive them, leading to the resident's caretakers being unaware of the condition until the HHA's assessment.
A facility failed to communicate necessary discharge information to a resident, their representative, and the home health agency. The resident, with multiple health issues, was discharged without receiving required instructions due to the representative leaving before signing paperwork. Additionally, the home health agency did not receive complete information about the resident's skin conditions, impacting ongoing care.
A facility's policy allowed late entries without a time limit, leading to a twelve-day delay in discharge planning notes for a resident. The DON acknowledged the resident left without signing discharge paperwork, and the SSD confirmed all notes were late entries. The policy was not reviewed by the governing body, and the practice was inconsistent with Medicare's expectations for timely documentation.
A facility failed to maintain a complete medical record for a resident when discharge planning notes were missing. The resident, discharged with home health services, left without signing discharge paperwork. The Social Services Director acknowledged that notes were entered as late entries six days post-discharge, just before a meeting with a Health Facility Evaluator Nurse. The facility's policy allowed for late entries without a specific time limit, conflicting with accepted standards requiring timely documentation.
A facility failed to accurately document fluid intake for two residents, leading to potential dehydration and hospital admissions. One resident was sent to the ER for shortness of breath and diagnosed with sepsis and pneumonia, while another was admitted with altered mental status, pneumonia, UTI, and sepsis. Discrepancies were found between daily intake totals and 24-hour records, and IV fluids were not included in the intake totals.
A resident with a urinary tract infection and chronic kidney disease was not properly communicated to their family representative about a change in condition. Despite being observed lethargic and having a urinalysis indicating infection, there was no documentation of notification to the responsible party. The resident was later transferred to the hospital due to altered mental status, contrary to the facility's policy requiring communication of such changes.
A facility failed to document a resident's intake and output as specified in the care plan, which was crucial due to the resident's risk for weight loss, malnutrition, dehydration, and fluid imbalance following surgery. The care plan required detailed monitoring and documentation of fluid intake and output, but records showed these were not closely monitored, leading to an inability to assess if hydration needs were met. The resident experienced a 5% weight loss shortly after admission, and the DON confirmed the missing documentation.
Damaged Corridor Wall with Moisture and Insect Infestation
Penalty
Summary
A deficiency was identified when surveyors observed a hole in the wall of the dining corridor leading from the dining room to the medical records office. The bottom wall siding was detached, creating an opening at the base of the wall, and several ants were seen entering and exiting through this opening. The wall damage was partially hidden by a lift device, and the charge nurse present during the observation confirmed the damage but was unaware of how long it had existed. Further inspection with the facilities director revealed that the inside of the wall was wet, and this was confirmed by touch. The facilities director could not explain the source of the moisture. The director of nursing was informed of the wet wall and the presence of ants, acknowledging the damage and the open area. The damaged area was not blocked off or marked with caution tape or signage to indicate ongoing repairs.
Failure to Ensure Timely and Accurate Physician Documentation and Medication Review
Penalty
Summary
The facility failed to ensure that the attending physician for a sampled resident conducted a review of the resident's medications at each required visit. Review of the facility's policy indicated that the physician should review the resident's total program of care, including medications, at each visit. However, examination of the resident's medical record revealed that the physician's progress notes consistently listed the same medications across multiple visits, despite documented changes in the resident's medication regimen throughout the year. Nursing progress notes and interdisciplinary team documentation showed that new medications and dosage changes were ordered at various times, but these updates were not reflected in the physician's progress notes. Additionally, the facility did not ensure that the physician wrote, signed, and dated a progress note at each required visit, nor that these notes were present in the resident's medical record. The medical records supervisor confirmed that there were no physician progress notes for the resident in either the hard copy or electronic medical record for the year in question until the physician was contacted and asked to provide them. The physician acknowledged that he had not sent any visit progress notes to the facility and that his notes were stored in his office system, which the facility did not have access to. Upon receiving the physician's notes, it was found that all notes for the year were created, documented, reviewed, and signed on the same day, well after the actual visit dates. This resulted in discrepancies regarding when the notes were performed and documented, and the progress notes did not accurately reflect the resident's current medication regimen at the time of each visit.
Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that a resident received timely physician visits as required. Upon review of the resident's medical record, it was found that the physician's visit notes for the year were missing from the record until the medical records supervisor (MRS) contacted the physician to obtain them. The notes provided showed that the intervals between some physician visits exceeded the required 60-day timeframe, with gaps of 86 and 91 days between visits. The facility's policy requires physician progress notes to be written at each visit, at least every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The deficiency was confirmed through interviews with the MRS and the director of nursing (DON), who acknowledged that the resident was not seen by the physician within the required intervals. The lack of timely physician evaluations was identified through a review of the visit notes and facility policy, and the DON confirmed that residents are to be seen at least once every 60 days with documentation at each visit.
Failure to Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper assessment and documentation of pressure ulcers for a resident, identified as Resident 2. A pressure ulcer on the right buttock was identified on 8/10/24, but no assessment was conducted or documented. During a review of the resident's medical records, it was confirmed by the assistant director of nursing and the treatment nurse that the initial assessment was not performed as required. Additionally, assessments for other pressure ulcers on the left buttock and sacrum were incomplete, lacking necessary details such as staging, measurements, and condition of the surrounding tissue. Furthermore, Resident 2 had refused to be turned and repositioned, as noted in the progress notes from 7/21/24 to 8/19/24. Despite this refusal, there were no documented assessments regarding the resident's refusal to turn and reposition. The director of nursing acknowledged the lack of documentation and did not provide an explanation for the missing assessments. The facility's policies on nursing assessment and pressure ulcer management were not adhered to, as ongoing assessments and documentation were not conducted as required.
Failure to Ensure Resident Dignity and Hygiene
Penalty
Summary
The facility failed to ensure that Resident 624 was treated with dignity and respect during and after a room change. During an observation, it was noted that Resident 624's call light and personal belongings were out of reach, leaving the resident unable to call for help if needed. The family member of Resident 624 was visibly upset and expressed concern about the resident's inability to communicate or access personal items. Interviews with the Housekeeping Supervisor and Director of Staff Development confirmed that housekeeping staff, rather than nursing staff, moved Resident 624, which was not in accordance with the facility's policy. The Director of Nursing also confirmed that moving residents was a nursing task, not a housekeeping duty. The facility also failed to ensure that Resident 31 was free of foul body odor, which could violate the resident's rights to quality care. During an observation, Resident 31 was found in bed with a stained hospital gown and sheets, tangled hair, and a strong, unpleasant odor. The resident stated a preference for bed baths but had not received one in several days. The facility's records indicated that Resident 31 received a sponge bath, but this was not observed during the inspection. Interviews with a CNA and the shower technician revealed a lack of clarity about when Resident 31 last received proper hygiene care, highlighting a failure in the facility's care practices.
Failure to Document Advance Directive in Re-admission Agreement
Penalty
Summary
The facility failed to ensure that an advance directive (AD) was noted in the re-admission agreement for a resident, which could potentially lead to the facility not honoring the resident's medical decisions regarding end-of-life treatment. The resident was readmitted to the facility, and although the AD was completed and signed prior to readmission, the re-admission agreement incorrectly indicated that the resident did not have an AD. This discrepancy was confirmed during a review of the resident's electronic health record and through interviews with the Director of Admission (DOA). The DOA acknowledged that the re-admission paperwork should have reflected the existence of the AD, which was presented to the facility upon the resident's readmission. The facility's policy and procedure on Physician Orders for Life-Sustaining Treatment (POLST) states that the POLST form should complement a resident's AD, but it does not replace it. The failure to accurately document the resident's AD in the re-admission agreement could lead to conflicts with the resident's healthcare wishes.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by issues in two resident rooms. During an observation and interview with the Housekeeping Supervisor, it was noted that a closet drawer in one resident's room could not be opened because it was off its track, and an electrical outlet cover was broken above another resident's bed. The Housekeeping Supervisor confirmed these issues and acknowledged the need for repairs. The facility's policy on maintaining a safe and homelike environment was reviewed, which indicated that housekeeping and maintenance services should be provided as necessary to ensure a sanitary, orderly, and comfortable environment. Additionally, the facility did not have monitoring logbooks for hot water temperature and air conditioning thermostat levels, as confirmed by the Maintenance Supervisor and Administrator. The facility's policies and procedures outlined specific standards for water and air temperatures in resident areas, but there was no evidence of regular monitoring or adjustments being made. This lack of monitoring had the potential to affect the residents' comfort and well-being, as the facility failed to ensure that environmental conditions met the established standards.
Failure to Address Resident's Refusal to Sit Upright While Eating
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident who refused to sit upright while eating, which posed a risk of choking and aspiration. The resident, who had multiple diagnoses including congestive heart failure, chronic respiratory failure, gastro-esophageal reflux disease, and a cognitive communication deficit, was observed eating while lying flat in bed. Despite the resident's preference to eat lying down due to pain and difficulty breathing when sitting up, the care plan did not include interventions to address this refusal or educate the resident on the associated risks. Interviews with facility staff, including a nurse supervisor, certified nurse assistant, licensed nurse, and the Director of Nursing, revealed that there were no documented interventions or physician notifications regarding the resident's refusal to eat upright. Additionally, there was no documentation in the medical record indicating that the risks of eating while lying down were explained to the resident or their representative. The facility's policy required the interdisciplinary team to develop a comprehensive care plan based on the resident's needs, which was not adhered to in this case.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring for signs and symptoms of bleeding for a resident who was prescribed the anticoagulant Eliquis. During an observation and record review, it was found that the medication administration record (MAR) for January 2025 indicated an order for Eliquis 2.5 mg to be taken twice daily. However, there was no documentation of monitoring for bleeding in the MAR. This was confirmed by the Minimum Data Set (MDS) coordinator, who verified the absence of monitoring for bleeding side effects in the resident's chart. The facility's policy and procedure on Medication Management, dated May 2022, requires ongoing monitoring for safe medication use, which was not adhered to in this case.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to dispose of expired medications according to its policy and procedure, which had the potential for expired medications to be administered to residents. During an observation and interview with a licensed nurse, three expired medications were found in medication cart two. These included one vial of Latanoprost 0.005% solution, one vial of Prednisolone Acetate 1%, and one vial of Brinzolamide 1%, all of which had an expiration date of 2/4/25. The licensed nurse acknowledged that the medications were expired and needed to be placed in the waste container in the medication room. The facility's policy on the storage of medications indicated that expired medications should be removed from use for appropriate disposal.
Failure to Follow Renal Diet Order
Penalty
Summary
The facility failed to adhere to a physician's order for a renal diet with no added salt (NAS) for a resident undergoing dialysis treatment. During an observation, a salt packet was found on the lunch tray of the resident, despite the diet order indicating a renal diet. The Registered Dietician confirmed that the resident's diet should not include added sodium. The Director of Staff Development, responsible for verifying meal trays, stated that the salt packet was not removed because the meal card did not specify NAS. A review of the resident's Order Summary confirmed the prescription of a renal NAS diet by the physician. The facility's policy on Liberal Renal Diets suggests consulting a licensed and registered dietician for individualized assessments, acknowledging that nutritional needs can vary among kidney patients.
Failure to Maintain Sanitary Conditions in Food Storage and Distribution
Penalty
Summary
The facility failed to adhere to its cleaning policy and procedures, resulting in unsanitary conditions in the food storage and distribution areas. During an observation, extensive debris and grime were found in and around the floor drain in the dry storage area. Additionally, produce, food scraps, and trash debris were observed behind and under metal racks in the walk-in refrigerator and behind the ice machine. The Registered Dietician and the Dietary Assistant Manager acknowledged that the drain was dirty and the floor appeared unswept and unmopped, contrary to the facility's policy that requires floors to be mopped at least once per day. Furthermore, the facility did not follow its policy for cleaning ice chests used to distribute ice to residents. The Ice Container Daily Cleaning Log for February 2025 showed that the ice chests were not cleaned on two specific days. The Dietary Assistant Manager confirmed the log was incomplete, indicating a failure to clean and sanitize the ice chests before and after each use, as required by the facility's policy. These lapses in cleaning procedures had the potential to cause foodborne illness among the highly susceptible resident population.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a resident on Enhanced Barrier Precaution (EBP). During an observation, an occupational therapist (OT) was seen assisting a resident without wearing a gown, which is required PPE for residents on EBP. The OT acknowledged the mistake and confirmed that the resident was on EBP due to an indwelling urinary catheter. Additionally, the OT improperly removed the gown outside the resident's room, contrary to the facility's policy that requires PPE to be discarded before exiting the room. Another deficiency was observed with a resident's oxygen and intravenous (IV) tubing. The oxygen tubing was not labeled, and the IV tubing lacked a date and nurse's initials, which are required by the facility's policy. A certified nurse assistant confirmed the absence of labeling, and the assistant director of nursing acknowledged the need for proper labeling per policy. Furthermore, respiratory care equipment for another resident was not stored correctly, risking cross-contamination. A nasal cannula and nebulizer mask were left exposed and not covered, contrary to the facility's practice of storing such equipment in plastic bags when not in use. Both a licensed nurse and the infection preventionist confirmed the improper storage, and the facility could not provide a policy addressing the proper storage of these items.
Failure to Respond to Call Lights as per Policy
Penalty
Summary
The facility failed to adhere to its call light policy and procedure, resulting in unmet needs for two residents. In the first instance, an unidentified staff member turned off the call light for a resident without addressing the resident's concern about a malfunctioning bed remote control. The resident had to activate the call light a second time for the same issue. The Infection Preventionist confirmed that the facility's policy requires call lights to remain on until the resident's issue is resolved, which was not followed in this case. In the second instance, a resident with significant medical conditions, including hemiplegia and encephalopathy, activated the call light for assistance with a soiled brief and getting out of bed. The Director of Staff Development entered the room, turned off the call light, and left without addressing the resident's needs or even acknowledging the resident's presence. The Director later admitted to not realizing the resident was in the room. The facility's policy mandates that staff must check in with residents and address their needs before turning off the call light, which was not adhered to in this situation.
Failure to Display Oxygen Use Signs
Penalty
Summary
The facility failed to ensure the safety of residents, staff, and visitors by not placing 'OXYGEN IN USE' signs outside the rooms of two residents who were receiving oxygen therapy. This deficiency was identified during observations and interviews conducted by surveyors. In one instance, the Housekeeping/Maintenance/Central Supply Supervisor confirmed that there was no sign outside the room of a resident on oxygen, despite acknowledging that it was the nurses' responsibility to ensure the sign was in place. Similarly, a Certified Nurse Assistant confirmed the absence of a required sign outside another resident's room who was also on oxygen. The facility's policy, dated November 2024, mandates the use of 'NO SMOKING/OXYGEN IN USE' signs to indicate when oxygen therapy is being administered, but this policy was not followed in these cases.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper physician justification for the use of the antianxiety medication Xanax beyond 14 days for a resident. The medication administration record indicated an order for Xanax 0.25 mg as needed for anxiety, which started on December 17, 2024, with a duration of 90 days. However, there was no documented rationale from the attending physician or prescribing practitioner to extend the PRN order beyond the 14-day limit as required by the Code of Federal Regulations. During the exit conference, the facility was unable to provide the appropriate policy on the use of as-needed psychotropic medication. Additionally, the facility did not obtain a physician's signature on informed consents for psychotherapeutic medications for another resident. The review of the facility's policy indicated that informed consent should be obtained by the prescriber when drugs are used to control behavior or treat a disordered thought process. However, the Facility Verification of Resident Informed Consent Psychotherapeutic Medications for several dates lacked a physician's signature. The Director of Nursing confirmed that the consents were missing the required physician signature.
Failure to Communicate Resident's Skin Condition to HHA
Penalty
Summary
The facility failed to ensure that appropriate and necessary information was communicated to the receiving home health agency (HHA) for a safe and effective transition of care for a resident. The resident, who was discharged to home with HHA services, had multiple diagnoses including pneumonia, acute respiratory failure, and mild cognitive impairment. Upon discharge, the resident's caretakers were not informed of the resident's pressure ulcers and moisture-associated skin damage (MASD) in various areas, including the groin, scrotal, and perirectal regions. This lack of communication resulted in a delay in necessary skin treatment until the HHA conducted an assessment and discovered a stage 2 pressure ulcer on the sacrum. The Social Services Director (SSD) stated that documents, including skin assessments, were faxed to the HHA, but the HHA Director of Patient Care Services reported not receiving any skin assessments or wound care orders. The order summary report faxed to the HHA did not include wound care instructions. The SSD later mentioned that the skin assessments were faxed separately but could not confirm their receipt. The HHA Chief Operating Officer confirmed that no separate fax or email regarding the skin assessments was received. This communication failure led to the resident's responsible party being unaware of the skin condition, delaying treatment.
Failure to Communicate Discharge Information
Penalty
Summary
The facility failed to communicate necessary discharge information to a resident, the resident's representative, and the continuing care provider at the time of an anticipated discharge. The resident, who had multiple diagnoses including pneumonia, acute respiratory failure, and mild cognitive impairment, was discharged to home without receiving the required discharge instructions. The resident's daughter, who was present during the discharge, did not sign the discharge paperwork and left the facility with the resident before the discharge information could be communicated. Additionally, the facility did not provide the home health agency with complete information regarding the resident's skin conditions, including pressure ulcers and other skin issues that required monitoring and treatment. The Order Summary Report sent to the home health agency lacked details about the resident's skin care needs, which were critical for ongoing care. This omission was confirmed by the Director of Patient Services, who noted that the home health agency did not receive information about the resident's pressure ulcers, resulting in a lack of appropriate care instructions for the resident's condition.
Deficiency in Timely Documentation of Late Entries
Penalty
Summary
The facility failed to ensure that its Late Entry documentation policy and procedure met professional standards for timely documentation. The policy in question stated that there was no time limit for writing a late entry, which led to a twelve-day delay in the availability of discharge planning notes in the medical record of a resident. This delay was identified during an interview with the Director of Nursing (DON), who acknowledged that the resident did not receive discharge information and left the facility without signing the necessary paperwork. The Social Services Director (SSD) later provided social services notes, which were all entered as late entries on the day of the interview, despite the conversations having occurred over a ten-day period earlier in the month. The facility's policy allowed staff to make late entries without a specific timeframe, which was confirmed by the SSD. The policy was not documented as having been reviewed by the governing body, and the DON could not provide documentation on when the policy was implemented or revised. The facility's practice of allowing late entries without a time limit was inconsistent with Medicare's expectations for timely documentation, which generally allows for delayed entries within a reasonable timeframe of 24 to 48 hours. This deficiency in documentation practices has the potential to compromise the timely continuity of care for residents.
Incomplete Medical Record Due to Missing Discharge Planning Notes
Penalty
Summary
The facility failed to maintain a complete medical record for a resident, as required by professional standards, when discharge planning notes were missing from the resident's medical record. The resident, who had been admitted with multiple diagnoses including pneumonia, acute respiratory failure with hypoxia, and mild cognitive impairment, was discharged to home with home health services. However, the discharge process was not properly documented, leading to a lack of discharge planning notes in the resident's medical record. During an interview, the Director of Nursing (DON) revealed that the resident left with family without signing the discharge paperwork. The Social Services Director (SSD) later acknowledged that all social services notes were entered as late entries, six days after the resident's discharge, and just before a meeting with a Health Facility Evaluator Nurse (HFEN). The facility's policy allowed for late entries without a specific time limit, but this practice did not align with accepted standards that require timely documentation. This failure had the potential to cause miscommunication and confusion among the healthcare team, affecting the resident's continuity of care.
Inaccurate Fluid Intake Documentation Leads to Hospital Admissions
Penalty
Summary
The facility failed to accurately document fluid intake for two residents, which potentially affected their hydration status and contributed to their hospital admissions. For the first resident, physician orders required recording fluid intake each shift and calculating the 24-hour intake on the night shift. However, discrepancies were found between the daily intake totals and the 24-hour intake records, which did not match as they should have. This resident was later sent to the emergency room for shortness of breath and diagnosed with sepsis and pneumonia. The second resident also had physician orders to record fluid intake each shift due to poor appetite, with an estimated fluid need of not less than 1500 cc/day. The intake records showed significant discrepancies, with daily totals not matching the 24-hour intake records and consistently falling below the recommended fluid intake. The resident had an IV infusion on specific dates, but the nursing staff failed to include these in the intake totals. This resident was admitted to the hospital with altered mental status, pneumonia, urinary tract infection, and sepsis. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the inaccuracies in the intake records for both residents. The facility's policy required intake and output to be recorded by each shift, but the records did not reflect this accurately. The ADON acknowledged that the intake totals were not accurate and that the physician was not informed of the resident's failure to meet the recommended fluid intake. Lab results for the second resident showed elevated blood urea nitrogen and creatinine levels, indicating potential dehydration.
Failure to Notify Family of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family representative of a change in condition for a resident who was readmitted with a urinary tract infection and chronic kidney disease. On May 6, the resident was observed to be sluggish and lethargic, prompting a physician to order a urinalysis. The test results on May 8 indicated blood in the urine, suggesting an infection, but there was no documentation of notification to the responsible party in the resident's medical record. On May 11, the resident was again found lethargic and was transferred to the hospital due to altered mental status. The facility's policy requires that routine changes, including abnormal laboratory results, be communicated to the physician and responsible party, with all attempts documented in the nursing progress notes.
Failure to Document Resident's Intake and Output
Penalty
Summary
The facility failed to ensure proper documentation of intake and output for a resident, which was specified in the care plan. The resident was at risk for weight loss, malnutrition, dehydration, and fluid and electrolyte imbalance due to recent surgery. The care plan required monitoring of intake and output every shift, recording total daily intake and output, and documenting the quality, color, odor, and consistency of urine, as well as the patient's hydration status. Additionally, any discrepancies in fluid intake or balance were to be reported to the physician every shift. A review of the resident's intake and output record revealed that these were not closely monitored, making it impossible to determine if the resident met her daily hydration requirements. The resident's weight summary indicated a 5% weight loss within 15 days of admission to the facility. During an interview, the DON confirmed the missing intake and output documentation for the resident.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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